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13 Articles in Volume 18, Issue #1
Applying a Collaborative Care Model to the Treatment of Chronic Pain and Depression
Assessing the Pain Triangle
Emerging Technologies in Rehabilitation Medicine
Honoring Dr. Forest Tennant’s 50-Plus Years in Pain Management
Is There a Chronic Pain Personality Profile?
Managing Musculoskeletal Pain in Endurance Athletes
Managing Perioperative Pain
Nonparenteral Oxytocin, Erythromelalgia...Letters from the Minds of Peers and Patients
OSKA PEMF Pain Relief Device: A Mini Review Trial
Patient Communication & Opioid Prescribing in the New Year
VR Gaming as a Tool for Pain Relief
What Opioid Shopping Means for Pain Practitioners
Would Patients Benefit from a Glucosamine/Chondroitin Supplement to Manage Knee Osteoarthritis Pain?

Patient Communication & Opioid Prescribing in the New Year

New, legacy, and perioperative patients with chronic pain warrant unique prescribing and treatment approaches.

As 2018 gets under way, efforts to reduce opioid prescribing and address addiction treatment continue. Bolstered by President Trump’s declaration of the issue as a national public health emergency last October, many practitioners remain fearful of prescribing opioids even when they know the medication may help a patient experiencing chronic pain. With this background in mind, Anish S. Patel, MD, of the National Spine & Pain Centers, addresses how healthcare providers may best communicate with patients presenting with chronic pain conditions – both new and legacy patients—including how to approach the opioid conversation.



Addressing Opioids with First-Time Pain Patients

The opioid epidemic has come front-and-center not only in healthcare but also in politics and, for this reason, physicians need to be well prepared to have a candid and thoughtful conversation with any patient presenting for initiation of opioid therapy. The CDC Guidelines1,2 provide a solid starting point for responsible prescribing as the guidelines address:

  • when to initiate opioids for chronic pain
  • selection, dosage, duration, follow-up, and discontinuation
  • assessing risk
  • addressing complications of chronic opioid use.

Each of these components should be discussed with the patient, and the conversation should be documented with an opioid agreement. These practice-specific documents are to be read and signed by the patient to ensure that any patient agreeing to opioid therapy understands the importance of complying with physician orders.

For example, the physician should discuss and ensure the patient understands what medication is recommended and why, and how the medication will be prescribed. In addition, the clinician needs to share his/her approach to requiring and prescribing urine toxicology testing screens, including timeframes, expectations, and when and if they may be conducted.

Other risk-mitigation strategies that may be put into place to deter misuse and abuse should also be shared. These strategies may include, for example, the utilization of prescription-drug monitoring programs, methods for detecting inappropriate prescribing and medical errors, provisions for safe disposal of unused opioids, referrals to an addiction specialist when appropriate, and the encouragement of the use of opioids with abuse-deterrent properties.

Most importantly, the physician should be prepared to enforce a physician-
patient opioid agreement to the best of ability, while also utilizing methods to prevent or minimize medication misuse, abuse, or deterrence. This type of thorough conversation with the patient is always the first step to safe opioid therapy for the purpose of benefiting patient health.

Continuing Opioid Therapy with Legacy Patients

Legacy patients may pose a specific dilemma when it comes to managing chronic opioid treatment in today’s healthcare system. The CDC guidelines1 have been adopted by numerous states with occasional modifications at the local level. The general consensus includes prescribing the lowest effective dosage and exercising caution when escalating opioid dosages.

Patients, who for years have been maintained on chronic opioids and have remained compliant without significant escalation in their dosages, should be permitted to continue their medication as long as it is clinically the lowest effective dose that provides sustained relief. It is crucial to document dosage and reported outcomes. Patients must also be held accountable for adhering to appropriate risk-mitigation strategies as noted above.

The history of a legacy patient, however, does not preclude the physician from discussing any potential changes in opioid prescribing. The physician must be prepared to have a conversation regarding future prescribing as well as alternative therapies, such as intrathecal opioid administration, as well as tapering. That said, legacy patients should be considered a subset of the chronic opioid population and thus be treated uniquely when continuation of opioid therapy and maintenance of analgesia is of primary concern.

A majority of legacy patients are fearful that their medication dosages will be systematically stopped given present state and federal regulations that aim to crack down on opioid prescribing and use. Reassurance, combined with open communication, can help allay this fear and allow appropriate patients to continue their present medications responsibly and safely.

Utilizing the WHO Pain Ladder

The World Health Organization (WHO) developed the analgesic ladder in 1986 as a simple approach to cancer pain treatment, and it has been extremely useful in teaching simple ideas of chronic pain control around the world. The scientific evidence supporting the use of the ladder, however, was limited when it was created and implemented. It provided a pragmatic approach in which the role of oral morphine—as a cheap and effective medication—was emphasized. Standards of care have changed significantly over the past 30 years, and the role of opioids and opioid alternatives alike has led to polarizing discussions regarding the future of chronic pain therapies and standards of implementation for both new and legacy patients.

Future iterations of the WHO ladder may require modifications given the potential role of a variety of new analgesic formulations and delivery methods, such as intrathecal infusion, as well as minimally invasive interventional procedures, such as minimally invasive lumbar decompression and spinal cord stimulation, which may alter the algorithmic approach to treating chronic pain.

While the WHO ladder continues to offer a well received and utilized framework for managing chronic pain, it will likely need to be updated to include new technologies and minimally invasive procedures to remain current with today’s pain management therapies and the issues surrounding chronic opioid therapy.

Considering Perioperative Pain Care

A primary focus of the media as well as the CDC guidelines1 on prescribing opioids has been to bring to light the outpatient problems affecting chronic pain patients. A wide variety of other medications, including but not limited to anticonvulsants and anti-inflammatory medications, as well as non-opioid analgesics are being used to try and reduce the amount of opioids a patient requires post-operatively.

Hospital, healthcare organizations, post-operative support teams, and anesthesiology departments are also incorporating interventional pain management techniques, such as neuraxial injections and peripheral nerve blocks (with and without catheters), to help control pain for as long as one week post-operatively if needed, thus minimizing potential opioid requirements of the post-surgical patient.

In accordance with surgeons, primary care physicians may develop an “exit strategy” ready for those patients at high risk of developing persistent opioid use after surgery. Thorough preoperative evaluations to identify high-risk patients (eg, those presenting with catastrophizing behavior, anxiety, depression, or those with prior high pain levels or opioid requirements) may help to preclude this population from developing persistent opioid misuse and escalation post-operatively.

To date, hospital teams have become more aggressive in identifying high-risk patients before surgery and developing reasonable post-operative analgesic plans. Independent perioperative pain management teams are being created at numerous hospitals and healthcare systems to supervise post-operative pain management, as well as to plan the patient’s discharge and continued care. The effort to develop this multimodal multidisciplinary approach to caring for the post-operative patient may minimize opioid requirements long-term.

Last updated on: January 31, 2018
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Abuse-Deterrent Guidelines Issued by FDA
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